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Behavioural activation (BA) therapy is as effective at treating depression as the ‘gold standard’ of cognitive behavioural therapy (CBT) – and can be delivered more cost-effectively, a large scale study has concluded.

BA encourages people to focus on meaningful activities driven by their own personal values as a way of overcoming depression. Due to its relative simplicity, BA can be delivered by more junior staff with less training, which helps to make it 20% cheaper than CBT, meaning it could help ease current difficulties in accessing therapy, and make it more realistic to deliver for a wider range of countries worldwide, the authors say.

Led by researchers from the University of Exeter, the multi-centre The Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA) study is one of the largest in the world to assess psychological treatments of depression through a randomised controlled trial, by comparing different treatments between groups.

The study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme and published in The Lancet. A collaborative team of researchers from the Universities of Exeter, York, Kings College London and Tees Esk and Wear Valleys NHS Foundation Trust (TEWV) worked with clinical services, to investigate the effectiveness and cost effectiveness of BA. The treatments were delivered by NHS mental health workers and therapists in NHS mental health trusts in Devon (Devon Partnership NHS Trust), County Durham (TEWV) and Leeds (Leeds and York Partnership NHS Foundation Trust).

Professor David Richards, NIHR senior investigator at the University of Exeter Medical School, led the study. He said: “Effectively treating depression at low cost is a global priority. Our finding is the most robust evidence yet that behavioural activation is just as effective as CBT, meaning an effective workforce could be trained much more easily and cheaply without any compromise on the high level of quality. This is an exciting prospect for reducing waiting times and improving access to high-quality depression therapy worldwide, and offers hope for countries who are currently struggling with the impact of depression on the health of their peoples and economies.”

BA is an ‘outside in’ treatment that focuses on helping people with depression to change the way they act. BA helps people make the link between their behaviour and their mood. Therapists help people to seek out and experience more positive situations in their lives. The treatment also helps people reduce the amount of times they avoid difficult situations and helps them find alternatives to unhelpful habitual behaviours.

In contrast, CBT is an ‘inside out’ treatment where therapists focus on the way a person thinks. Therapists help people to identify and challenge their thoughts and beliefs about themselves, the world and their future. CBT helps people to identify and modify negative thoughts and the beliefs that give rise to them.

While CBT is known to be effective, access is often restricted, with long waiting lists. In England, 1 in 10 people have been waiting more than a year to receive talking therapy. Part of the reason for this is the cost of delivery. Typically, a CBT therapist earns £31,383 to £41,373, while a BA therapist earns £21,909 to £28,462, making BA much cheaper to deliver. On average, CBT costs £1,235 per participant, while BA costs £975 – a saving of £260 per patient.

Growing evidence

Yet, until now, the National Institute for Health and Clinical Excellence has said there is insufficient evidence to recommend BA as a first-line treatment in clinical guidelines, and has called for more robust research to investigate the benefits. COBRA trial, one of the largest of its kind in the world, was designed to meet this need.

The trial recruited participants from primary care and psychological services in three sites in Devon, Durham and Leeds. The 440 participants were split into two groups – 219 were given CBT and 221 received BA. The groups were followed up and assessed at 6, 12 and 18 months. The researchers found no difference between the groups at follow-up, providing the strongest evidence to date that BA is just as effective as CBT.

A year after the start of treatment, BA was found to be non-inferior than CBT, with around two-thirds of participants in both groups reporting at least a 50% reduction in depressive symptoms. Participants in both groups also reported similar numbers of depression-free days and anxiety diagnoses, and were equally likely to experience remission. Cost of delivery for BA therapy was found to be about 20% cheaper than CBT.

In line with other trials of a similar nature, drop-out rates were around 20% and around a third of participants in both groups did not attend the minimum number of therapy sessions.

Dr Peter Aitken, director of research and development at Devon Partnership NHS Trust, said: “Research into psychological therapies and mental health is incredibly important and we are always looking for treatments and approaches that offer people better outcomes and, wherever possible, improved cost efficiency. Last year our Depression and Anxiety Service in Devon, which supports people with mild to moderate needs, received 20,000 referrals and we know that the incidence of depression is steadily increasing. Contributing to the research agenda and taking forward treatments such as Behavioural Activation is vital if our services are to keep pace with this rising demand and offer value for money.”

Dr David Ekers, nurse consultant from TEWV, who led the Durham study site, said: “The practical nature of BA and the relative simplicity of delivery makes it an attractive option for NHS services. We have already seen considerable interest within TEWV to make this effective intervention more available to its service users. Whilst we must ensure ongoing quality to reflect what was provided in the COBRA study, this intervention will offer a cost effective option to provide evidence based psychological interventions for depression across a range of clinical teams.”

Study welcomed

Dr Liz England, clinical lead for mental health for the Royal College of GPs, welcomed the study’s findings. “Cognitive behavioural therapy can be beneficial to our patients with mental health problems, but evidence suggests that Behavioural Action treatment is also effective. Given that, as this study suggests, BA is more cost-effective, it is definitely something we should explore commissioning further, especially at a time when the health service is facing such intense financial pressure.

“Greater access to BA, along with the other measures to support GPs deliver the best possible care to patients with mental health problems, outlined in NHS England’s GP Forward View, could go a long way to achieving the parity of esteem between mental and physical health that the College is striving for.

“Of course, it is essential that any shift in the services we provide to patients with mental health conditions does not negatively impact on the level of care they receive, so any initiative would need to be constantly evaluated.”